Provider First Line Business Practice Location Address:
32 GRACE DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRESTONSBURG
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41653-8792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-886-9456
Provider Business Practice Location Address Fax Number:
606-886-9896
Provider Enumeration Date:
10/31/2007